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Screening for Chlamydia trachomatis in Asymptomatic Women Attending Family Planning Clinics: A Cost-Effectiveness Analysis of Three Strategies

M. Rene Howell, MA; Thomas C. Quinn, MD; and Charlotte A. Gaydos, DrPH
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From Johns Hopkins University, Baltimore, Maryland; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland. Acknowledgments: The authors thank Wayne Brathwaite, Nicole Novak, Samantha Johnston, and the family planning clinicians for their support. Requests for Reprints: M. Rene Howell, MA, Johns Hopkins University, Division of Infectious Diseases, Ross Research Building, Room 1159, 720 Rutland Avenue, Baltimore, MD 21205. Current Author Addresses: Ms. Howell and Drs. Quinn and Gaydos: Johns Hopkins University, Division of Infectious Diseases, Ross Research Building, Room 1159, 720 Rutland Avenue, Baltimore, MD 21205.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;128(4):277-284. doi:10.7326/0003-4819-128-4-199802150-00005
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Background: Screening women for Chlamydia trachomatis in family planning clinics is associated with a reduced incidence of chlamydial sequelae. However, the question of whom to screen to maintain efficient use of resources remains controversial.

Objective: To assess the cost-effectiveness of chlamydial screening done according to three sets of criteria in asymptomatic women attending family planning clinics.

Design: Cost-effectiveness analysis done by using a decision model with the perspective of a health care system. Model estimates were based on analysis of cohort data, clinic costs, laboratory costs, and published data.

Setting: Two family planning clinics in Baltimore, Maryland.

Patients: 7699 asymptomatic women who presented between April 1994 and August 1996.

Intervention: Three screening strategies-screening according to the criteria of the Centers for Disease Control and Prevention (CDC), screening all women younger than 30 years of age, and universal screening-were retrospectively applied and compared. All women were tested with polymerase chain reaction.

Measurements: Medical outcomes included sequelae prevented in women, men, and infants. Total costs included screening program costs and future medical costs of all sequelae. The incremental cost-effectiveness ratios of each strategy were calculated.

Results: Without screening, 152 cases of pelvic inflammatory disease would occur at a cost of $676 000. Screening done by using the CDC criteria would prevent 64 cases of pelvic inflammatory disease at a cost savings of $231 000. Screening all women younger than 30 years of age would prevent an additional 21 cases of pelvic inflammatory disease and save $74 000. Universal screening would prevent an additional 6 cases of pelvic inflammatory disease but would cost $19 000 more than age-based screening, or approximately $3000 more per case of pelvic inflammatory disease prevented. If the prevalence of C. trachomatis is more than 10.2% or if less than 88.5% of infections occur in women younger than 30 years of age, universal screening provides the greatest cost savings.

Conclusions: These results suggest that age-based screening provides the greatest cost savings of the three strategies examined. However, universal screening is desirable in some situations. In general, screening done by using any criteria and a highly sensitive diagnostic assay should be part of any chlamydial prevention and control program or health plan.


Grahic Jump Location
Figure 1.
Cost-effectiveness of age-based screening and universal screening at various prevalences of chlamydial infection.

Curve = (universal screening $) −(age-based screening $)/(universal testing pelvic inflammatory disease) −(age-based screening pelvic inflammatory disease). As the prevalence of chlamydial infection increases, the age-based screening strategy becomes less cost-saving relative to universal screening. At prevalences greater than 10.2%, universal screening prevents more disease and provides more cost savings than age-based screening. The break-even prevalence for all screening is 1.1%; this is the point at which screening by any criteria ceases to provide cost savings. PID = pelvic inflammatory disease.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Screening strategy recommendations based on different prevalences of chlamydial infection and different sensitivities of age-based screening.

The line represents the break-even values for prevalence of chlamydial infection and sensitivity of age-based screening, where age-based screening and universal screening provide the same cost savings. For example, at prevalences greater than 4.5%, where age-based screening fails to identify more than 82.2% of infections occurring in the population, universal screening provides greater cost savings than age-based screening.

Grahic Jump Location




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